xi

Preface

The rapid advances in neonatology in the last 15 years have

brought with them a welter of special procedures. The tiny,

premature, and the critically ill term neonate is attached to

a tangle of intravenous lines, tubes, and monitoring leads.

As a result, more and more procedures are done at the bedside in the intensive-care nursery, rather than in a procedure room or operating room. With these technical advances

has come the opportunity for more vigorous physiologic

support and monitoring. With them also has come a whole

new gamut of side-effects and complications. The old dictum to leave the fragile premature undisturbed is largely

ignored. It is therefore the responsibility of those who care

for sick newborns to understand the complications as well

as the benefits of new procedures and to make systematic

observations of their impact on both morbidity and mortality. Unfortunately, the literature on outcome and complications of procedures is widely scattered and difficult to

access. Manuals that give directions for neonatal procedures are generally deficient in illustrations giving anatomic

detail and are often cursory.

We are offering Atlas of Procedures in Neonatology to

meet some of these needs. A step-by-step, practical approach

is taken, with telegraphic prose and outline form. Drawings

and photographs are used to illustrate anatomic landmarks

and details of the procedures. In several instances, more than

one alternative procedure is presented. Discussion of controversial points is included, and copious literature citations are

provided to lead the interested reader to source material. A

uniform order of presentation has been adhered to wherever

appropriate. Thus, most chapters include indications, contraindications, precautions, equipment, technique, and complications, in that order.

The scope of procedures covered includes nearly all

those that can be performed at the bedside in an intensivecare nursery. Some are within the traditional province of

the neonatologist or even the pediatric house officer.

Others, such as gastrostomy and tracheostomy, require skills

of a qualified surgeon. Responsibility for procedures such as

placement of chest tubes and performance of vascular cutdowns will vary from nursery to nursery. However, some

details of surgical technique are supplied for even the most

invasive procedures to promote their understanding by

those who are responsible for sick neonates. We hope this

will help neonatologists to be more knowledgeable partners

in caring for babies and will not be interpreted as a license

to perform procedures by those who are not adequately

qualified.

The book is organized into major parts (e.g., “Vascular

Access,” “Tube Placement,” “Respiratory Care”), each of

which contains several chapters. Most chapters are relatively self-contained and can be referred to when approaching a particular task. However, Part I, “Preparation and

Support,” is basic to all procedures. Occasional cross referencing has been used to avoid repetitions of the same text

material. References appear at the end of each part.

Many persons have contributed to the preparation of

this atlas, and we are grateful to them all. Some are listed

under Acknowledgments, and others have contributed

anonymously out of their generosity and good will. Special

thanks is due to Bill Burgower, who first thought of making

such an atlas and who has been gracious in his support

throughout this project.

If this atlas proves useful to some who care for sick newborns, our efforts will have been well repaid. Neonatology is

a taxing field: strenuous, demanding, confusing, heartbreaking, rewarding, stimulating, scientific, personal, philosophical, cooperative, logical, illogical, and always changing. The

procedures described in this atlas will eventually be replaced

by others, hopefully more effective and less noxious. In the

meantime, perhaps the care of some babies will be assisted.

Mary Ann Fletcher, MD

Mhairi G. MacDonald, MBChB,

FRCP(E), DCH

Gordon B. Avery, MD, PhD

to the First Edition